Proxy Pattern-Mixture Analysis for Survey Nonresponse

We consider assessment of nonresponse bias for the mean of a survey variable Y subject to nonresponse. We assume that there are a set of covariates observed for nonrespondents and respondents. To reduce dimensionality and for simplicity we reduce the covariates to a proxy variable X that has the highest correlation with Y , estimated from a regression analysis of respondent data. We consider adjusted estimators of the mean of Y that are maximum likelihood for a pattern-mixture model with dierent mean and covariance matrix of Y and X for respondents and nonrespondents, assuming missingness is an arbitrary function of a known linear combination of X and Y . We propose a taxonomy for the evidence concerning bias based on the strength of the proxy and the deviation of the mean of X for respondents from its overall mean, propose a sensitivity analysis, and describe Bayesian versions of this approach. Methods are demonstrated through data from the third National Health and Nutrition Examination Survey (NHANES III).

Early Outcomes From the English National Health Service Diabetes Prevention Programme

OBJECTIVE To assess weight and HbA1c changes in the Healthier You: National Health Service Diabetes Prevention Programme (NHS DPP), the largest DPP globally to achieve universal population coverage. RESEARCH DESIGN AND METHODS A service evaluation assessed intervention effectiveness for adults with nondiabetic hyperglycemia (HbA1c 42–47 mmol/mol [6.0–6.4%] or fasting plasma glucose 5.5–6.9 mmol/L) between program launch in June 2016 and December 2018, using prospectively collected, national service–level data in England. RESULTS By December 2018, 324,699 people had been referred, 152,294 had attended the initial assessment, and 96,442 had attended at least 1 of 13 group-based intervention sessions. Allowing sufficient time to elapse, 53% attended an initial assessment, 36% attended at least one group-based session, and 19% completed the intervention (attended >60% of sessions). Of the 32,665 who attended at least one intervention session and had sufficient time to finish, 17,252 (53%) completed: intention-to-treat analyses demonstrated a mean weight loss of 2.3 kg (95% CI 2.2, 2.3) and an HbA1c reduction of 1.26 mmol/mol (1.20, 1.31) (0.12% [0.11, 0.12]); completer analysis demonstrated a mean weight loss of 3.3 kg (3.2, 3.4) and an HbA1c reduction of 2.04 mmol/mol (1.96, 2.12) (0.19% [0.18, 0.19]). Younger age, female sex, Asian and black ethnicity, lower socioeconomic status, and normal baseline BMI were associated with less weight loss. Older age, female sex, black ethnicity, lower socioeconomic status, and baseline overweight and obesity were associated with a smaller HbA1c reduction. CONCLUSIONS Reductions in weight and HbA1c compare favorably with those reported in recent meta-analyses of pragmatic studies and suggest likely future reductions in participant type 2 diabetes incidence.

Investigation of maternal environmental exposures in association with self-reported preterm birth.

Development and Internal Validation of the Male Osteoporosis Risk Estimation Score

PURPOSE We wanted to develop and validate a clinical prediction rule to identify men at risk for osteoporosis and subsequent hip fracture who might benefit from dual-energy x-ray absorptiometry (DXA). METHODS We used risk factor data from the National Health and Nutrition Examination Survey III to develop a best fitting multivariable logistic regression model in men aged 50 years and older randomized to either the development (n = 1,497) or validation (n = 1,498) cohorts. The best fitting model was transformed into a simplified scoring algorithm, the Male Osteoporosis Risk Estimation Score (MORES). We validated the MORES, comparing sensitivity, specificity, and area under the receiver operating characteristics (ROC) curve in the 2 cohorts and assessed clinical utility with an analysis of the number needed-to-screen (NNS) to prevent 1 additional hip fracture. RESULTS The MORES included 3 variables—age, weight, and history of chronic obstructive pulmonary disease—and showed excellent predictive validity in the validation cohort. A score of 6 or greater yielded an overall sensitivity of 0.93 (95% CI, 0.85–0.97), a specificity of 0.59 (95% CI, 0.56–0.62), and an area under the ROC curve of 0.832 (95% CI, 0.807–0.858). The overall NNS to prevent 1 additional hip fracture was 279 in a cohort of men representative of the US population. CONCLUSIONS Osteoporosis is a major predictor of hip fractures. Experts believe bisphosphonate treatment in men should yield results similar to that in women and reduce hip fracture rates associated with osteoporosis. In men aged 60 years and older, the MORES is a simple approach to identify men at risk for osteoporosis and refer them for confirmatory DXA scans.

Excess deaths associated with underweight, overweight, and obesity.

CONTEXT As the prevalence of obesity increases in the United States, concern over the association of body weight with excess mortality has also increased. OBJECTIVE To estimate deaths associated with underweight (body mass index [BMI] <18.5), overweight (BMI 25 to <30), and obesity (BMI > or =30) in the United States in 2000. DESIGN, SETTING, AND PARTICIPANTS We estimated relative risks of mortality associated with different levels of BMI (calculated as weight in kilograms divided by the square of height in meters) from the nationally representative National Health and Nutrition Examination Survey (NHANES) I (1971-1975) and NHANES II (1976-1980), with follow-up through 1992, and from NHANES III (1988-1994), with follow-up through 2000. These relative risks were applied to the distribution of BMI and other covariates from NHANES 1999-2002 to estimate attributable fractions and number of excess deaths, adjusted for confounding factors and for effect modification by age. MAIN OUTCOME MEASURES Number of excess deaths in 2000 associated with given BMI levels. RESULTS Relative to the normal weight category (BMI 18.5 to <25), obesity (BMI > or =30) was associated with 111,909 excess deaths (95% confidence interval [CI], 53,754-170,064) and underweight with 33,746 excess deaths (95% CI, 15,726-51,766). Overweight was not associated with excess mortality (-86,094 deaths; 95% CI, -161,223 to -10,966). The relative risks of mortality associated with obesity were lower in NHANES II and NHANES III than in NHANES I. CONCLUSIONS Underweight and obesity, particularly higher levels of obesity, were associated with increased mortality relative to the normal weight category. The impact of obesity on mortality may have decreased over time, perhaps because of improvements in public health and medical care. These findings are consistent with the increases in life expectancy in the United States and the declining mortality rates from ischemic heart disease.

Predicting overweight and obesity in adulthood from body mass index values in childhood and adolescence.

BACKGROUND The Centers for Disease Control and Prevention (CDC) introduced the clinical use of the body mass index (BMI; in kg/m(2)) in growth charts for young males and females. OBJECTIVE This study updates our previous report with the use of new CDC BMI charts and definitions of adult overweight and obesity to predict adult overweight or obesity. DESIGN Logistic models were fitted to relate adult overweight and obesity to childhood and adolescent BMI values at each age for 166 males and 181 females in the Fels Longitudinal Study and were applied to predict adult overweight and obesity at the 75th, 85th, and 95th percentiles on the CDC charts of childhood and adolescent BMI. RESULTS A child or adolescent with a high BMI percentile on the CDC BMI-for-age growth charts has a high risk of being overweight or obese at 35 y of age, and this risk increases with age. For example, the probability of adult obesity at the 85th percentile for young males was </=20% to 17 y of age and 20-59.9% afterward; the corresponding probability for young females was 20-39.9% to 18 y of age and 40-59.9% afterward. CONCLUSION Our clinically applicable method assigns a child's or adolescent's BMI value to a group with a known probability of overweight or obesity in adulthood.

Health-related quality of life and hypertension status, awareness, treatment, and control: National Health and Nutrition Examination Survey, 2001–2004

Objective We examined health-related quality of life measures by hypertension status, awareness, treatment, and control. Methods Five unfavorable health-related quality of life measures were analyzed among 8303 adults aged 20 years or older who participated in the 2001–2004 National Health and Nutrition Examination Survey. Multivariable logistic regression analyses examined differences in health-related quality of life with adjustment for age, race, sex, healthcare coverage, and other medical conditions. Results The 30% of respondents with hypertension were more likely to report fair or poor health status (adjusted odds ratio 1.72, 95% confidence interval 1.44–2.05), 14 or more unhealthy days in the past 30 days (1.23, 1.06–1.43), 14 or more physically unhealthy days (1.39, 1.15–1.67), and 14 or more activity-limited days (1.55, 1.17–2.04) than those without hypertension. Among adults with hypertension, the 73.2% who were aware of their condition were more likely to report fair or poor health status (2.19, 1.54–3.12), 14 or more unhealthy days (1.53, 1.12–2.09), 14 or more physically unhealthy days (1.49, 1.10–2.03), 14 or more mentally unhealthy days (1.70, 1.05–2.75), and 14 or more activity-limited days (2.38, 1.39–4.05) than those who were unaware. Among those aware they had hypertension, 14 or more physically unhealthy days (0.50, 0.28–0.90) was associated with current treatment. Health-related quality of life measures did not differ by blood pressure control status. Conclusions Having hypertension and being aware of it was related to lower health-related quality of life. Antihypertensive medication was associated with more physically unhealthy days, while there were no differences in health-related quality of life by control status. Further study is needed to examine these differences including: disease severity, sex and racial/ethnic differences, comorbidities not examined, and impact of health-related quality of life and its changes on outcomes.

Postural change in blood pressure associated with age and systolic blood pressure. The National Health and Nutrition Examination Survey II.

The prevalence of postural change in blood pressure and its association with age and systolic blood pressure were examined in data from 8,574 White nondiabetic persons aged 25-74 who participated in the second National Health and Nutrition Examination Survey (1976-1980). Postural change in blood pressure was defined as a drop of 20 mm Hg or more on change from supine to seated position. In subjects on no antihypertensive medications (n = 7,316), the prevalence of postural change in blood pressure increased with older age and with higher blood pressure levels, regardless of age. However, systolic blood pressure levels also increased with age. In logistic regression models, level of supine systolic blood pressure was strongly related to postural change in blood pressure (Relative odds (RO) = 1.59, 95% confidence interval (CI) = 1.49, 1.70 for a 10 mm Hg increase in systolic blood pressure) whereas age was not related to postural change in blood pressure (RO for age = 1.07, Cl = .89, 1.19 for a 10-year increase in age). Results were similar for those medicated for hypertension. All results were unchanged by addition of health status indicators, including reports of hospitalization and number of medical conditions, to the model. These data suggest that the age-related increase in the prevalence of postural hypotension previously reported may be partially explained by age-associated increases in systolic blood pressure.

Bone density-related predictors of blood lead level among peri- and postmenopausal women in the United States: The Third National Health and Nutrition Examination Survey, 1988-1994.

Because of the long half-life of lead stored in bone (years), skeletal lead stores may be a source of endogenous lead exposure during periods of increased bone demineralization, such as menopause. To test the hypothesis that postmenopausal bone resorption increases blood lead levels, the authors examined cross-sectional associations of bone density-related factors with blood lead levels among women aged 40-59 years from the Third National Health and Nutrition Examination Survey (1988-1994). Factors related to bone turnover were significant predictors of blood lead level. Bone mineral density was significantly inversely related to blood lead levels in log-linear multivariate models that adjusted for age, race/ethnicity, smoking, education, household income, alcohol use, and residence (urban/rural). With menopausal status added to the model, naturally and surgically menopausal women had adjusted median blood lead levels that were 25% and 30% higher, respectively, than those of premenopausal women (2.0 microg/dl). Current use of hormone replacement therapy was associated with significantly lower adjusted median blood lead levels (1.8 microg/dl) than past use (2.6 microg/dl) and never use (2.2 microg/dl). Lead stored in bone may significantly increase blood lead levels in perimenopausal women because of postmenopausal bone mineral resorption. Attention to factors that prevent bone loss may lessen or prevent this endogenous lead exposure.

Serum Antioxidant Concentrations Among U.S. Adults with Self‐Reported Asthma

Antioxidants may protect the lungs of people with asthma against oxidative stress. Among participants aged ≥ 20 years from the Third National Health and Nutrition Examination Survey (1988–1994), we examined serum antioxidant concentrations of 771 persons with current asthma, 352 persons with former asthma, and 15,418 persons without asthma. After adjustment for age, participants with current asthma had similar mean concentrations of vitamin A, retinyl esters, vitamin C, vitamin E, vitamin E/cholesterol ratio, vitamin E/triglyceride ratio, α‐carotene, β‐carotene, β‐cryptoxanthin, lutein/zeaxanthin, lycopene, and selenium as participants without asthma. We repeated these analyses among participants who did not use vitamin or mineral supplements. After age adjustment, participants with current asthma had lower vitamin C and β‐cryptoxanthin concentrations and a lower mean vitamin E/triglyceride ratio than participants without asthma. In multiple linear regression models that included age, sex, race or ethnicity, education, smoking status, nonhigh‐density lipoprotein cholesterol concentration, high‐density lipoprotein cholesterol concentration, body mass index, physical activity, and alcohol use, asthma status was not significantly associated with any of the antioxidant concentrations. However, lower vitamin C concentrations were observed among people with current or former asthma than among people who never had asthma (p = 0.014). In the United States, people with asthma do not have manifest antioxidant deficiencies.

Predictors of hemoglobin A1c in a national sample of nondiabetic children: the Third National Health and Nutrition Examination Survey, 1988-1994.

Hemoglobin A1c (HbA1c) is related to glucose metabolism in diabetic and nondiabetic persons. Analysis of factors related to HbA1c may help researchers to better identify children with an increased likelihood of developing type 2 diabetes mellitus. In this study, the authors investigated predictors of HbA1c percentage among 1,700 Mexican-American, 1,787 African-American, and 1,441 non-Hispanic White young people aged 4-17.0 years who were free of diabetes and were examined in the Third National Health and Nutrition Examination Survey (1988-1994). HbA1c was positively related to age and body mass index (p = 0.065 and p = 0.008, respectively) and negatively related to an indicator of socioeconomic status, the poverty income ratio (p = 0.008). African Americans and Mexican Americans had higher mean HbA1c percentages than non-Hispanic Whites after data were controlled for age, sex, body mass index, maternal body mass index, and poverty income ratio. While some inconsistencies emerged, HbA1c was generally associated with other known risk factors for type 2 diabetes in young people. This report provides representative data on HbA1c percentage among nondiabetic children. However, further investigation will be needed to better understand the utility of HbA1c and its relation to type 2 diabetes in youth.

Prevalence of overweight, obesity, and severe obesity among adults aged 20 and over: United States, 1960–1962 through 2015–2016

Results from the 2015–2016 National Health and Nutrition Examination Survey (NHANES), using measured heights and weights, indicate that an estimated 39.8% of U.S. adults aged 20 and over have obesity, including 7.6% with severe obesity, and another 31.8% are overweight. Body mass index (BMI), expressed as weight in kilograms divided by height in meters squared (kg/m2), is commonly used to classify overweight (BMI 25.0–29.9), obesity (BMI at or above 30.0), and severe obesity (BMI at or above 40.0).

Secular Changes in U.S. Prediabetes Prevalence Defined by Hemoglobin A1c and Fasting Plasma Glucose

OBJECTIVE Using a nationally representative sample of the civilian noninstitutionalized U.S. population, we estimated prediabetes prevalence and its changes during 1999–2010. RESEARCH DESIGN AND METHODS Data were from 19,182 nonpregnant individuals aged ≥12 years who participated in the 1999–2010 National Health and Nutrition Examination Surveys. We defined prediabetes as hemoglobin A1c (A1C) 5.7 to <6.5% (39 to <48 mmol/mol, A1C5.7) or fasting plasma glucose (FPG) 100 to <126 mg/dL (impaired fasting glucose [IFG]). We estimated the prevalence of prediabetes, A1C5.7, and IFG for 1999–2002, 2003–2006, and 2007–2010. We calculated estimates age-standardized to the 2000 U.S. census population and used logistic regression to compute estimates adjusted for age, sex, race/ethnicity, poverty-to-income ratio, and BMI. Participants with self-reported diabetes, A1C ≥6.5% (≥48 mmol/mol), or FPG ≥126 mg/dL were included. RESULTS Among those aged ≥12 years, age-adjusted prediabetes prevalence increased from 27.4% (95% CI 25.1–29.7) in 1999–2002 to 34.1% (32.5–35.8) in 2007–2010. Among adults aged ≥18 years, the prevalence increased from 29.2% (26.8–31.8) to 36.2% (34.5–38.0). As single measures among individuals aged ≥12 years, A1C5.7 prevalence increased from 9.5% (8.4–10.8) to 17.8% (16.6–19.0), a relative increase of 87%, whereas IFG remained stable. These prevalence changes were similar among the total population, across subgroups, and after controlling for covariates. CONCLUSIONS During 1999–2010, U.S. prediabetes prevalence increased because of increases in A1C5.7. Continuous monitoring of prediabetes is needed to identify, quantify, and characterize the population of high-risk individuals targeted for ongoing diabetes primary prevention efforts.

Prevalence of the metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey.

CONTEXT The Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) highlights the importance of treating patients with the metabolic syndrome to prevent cardiovascular disease. Limited information is available about the prevalence of the metabolic syndrome in the United States, however. OBJECTIVE To estimate the prevalence of the metabolic syndrome in the United States as defined by the ATP III report. DESIGN, SETTING, AND PARTICIPANTS Analysis of data on 8814 men and women aged 20 years or older from the Third National Health and Nutrition Examination Survey (1988-1994), a cross-sectional health survey of a nationally representative sample of the noninstitutionalized civilian US population. MAIN OUTCOME MEASURES Prevalence of the metabolic syndrome as defined by ATP III (>/=3 of the following abnormalities): waist circumference greater than 102 cm in men and 88 cm in women; serum triglycerides level of at least 150 mg/dL (1.69 mmol/L); high-density lipoprotein cholesterol level of less than 40 mg/dL (1.04 mmol/L) in men and 50 mg/dL (1.29 mmol/L) in women; blood pressure of at least 130/85 mm Hg; or serum glucose level of at least 110 mg/dL (6.1 mmol/L). RESULTS The unadjusted and age-adjusted prevalences of the metabolic syndrome were 21.8% and 23.7%, respectively. The prevalence increased from 6.7% among participants aged 20 through 29 years to 43.5% and 42.0% for participants aged 60 through 69 years and aged at least 70 years, respectively. Mexican Americans had the highest age-adjusted prevalence of the metabolic syndrome (31.9%). The age-adjusted prevalence was similar for men (24.0%) and women (23.4%). However, among African Americans, women had about a 57% higher prevalence than men did and among Mexican Americans, women had about a 26% higher prevalence than men did. Using 2000 census data, about 47 million US residents have the metabolic syndrome. CONCLUSIONS These results from a representative sample of US adults show that the metabolic syndrome is highly prevalent. The large numbers of US residents with the metabolic syndrome may have important implications for the health care sector.

Structural Trends in the Aging Femoral Neck and Proximal Shaft: Analysis of the Third National Health and Nutrition Examination Survey Dual‐Energy X‐Ray Absorptiometry Data

Hip scans of U.S. adults aged 20–99 years acquired in the Third National Health and Nutrition Examination Survey (NHANES III) using dual‐energy X‐ray absorptiometry (DXA) were analyzed with a structural analysis program. The program analyzes narrow (3 mm wide) regions at specific locations across the proximal femur to measure bone mineral density (BMD) as well as cross‐sectional areas (CSAs), cross‐sectional moments of inertia (CSMI), section moduli, subperiosteal widths, and estimated mean cortical thickness. Measurements are reported here on a non‐Hispanic white subgroup of 2719 men and 2904 women for a cortical region across the proximal shaft 2 cm distal to the lesser trochanter and a mixed cortical/trabecular region across the narrowest point of the femoral neck. Apparent age trends in BMD and section modulus were studied for both regions by sex after correction for body weight. The BMD decline with age in the narrow neck was similar to that seen in the Hologic neck region; BMD in the shaft also declined, although at a slower rate. A different pattern was seen for section modulus; furthermore, this pattern depended on sex. Specifically, the section modulus at both the narrow neck and the shaft regions remains nearly constant until the fifth decade in females and then declined at a slower rate than BMD. In males, the narrow neck section modulus declined modestly until the fifth decade and then remained nearly constant whereas the shaft section modulus was static until the fifth decade and then increased steadily. The apparent mechanism for the discord between BMD and section modulus is a linear expansion in subperiosteal diameter in both sexes and in both regions, which tends to mechanically offset net loss of medullary bone mass. These results suggest that aging loss of bone mass in the hip does not necessarily mean reduced mechanical strength. Femoral neck section moduli in the elderly are on the average within 14% of young values in females and within 6% in males.

Serum 25-hydroxyvitamin D, diabetes, and ethnicity in the Third National Health and Nutrition Examination Survey.

OBJECTIVE To determine the association between serum 25-hydroxyvitamin D (25OHD) and diabetes risk and whether it varies by ethnicity. RESEARCH DESIGN AND METHODS We performed an analysis of data from participants who attended the morning examination of the Third National Health and Nutrition Examination Survey (1988-1994), a cross-sectional survey of a nationally representative sample of the U.S. population. Serum levels of 25OHD, which reflect vitamin D status, were available from 6,228 people (2,766 non-Hispanic whites, 1,736 non-Hispanic blacks, and 1,726 Mexican Americans) aged > or =20 years with fasting and/or 2-h plasma glucose and serum insulin measurements. RESULTS Adjusting for sex, age, BMI, leisure activity, and quarter of year, ethnicity-specific odds ratios (ORs) for diabetes (fasting glucose > or =7.0 mmol/l) varied inversely across quartiles of 25OHD in a dose-dependent pattern (OR 0.25 [95% CI 0.11-0.60] for non-Hispanic whites and 0.17 [0.08-0.37] for Mexican Americans) in the highest vitamin D quartile (25OHD > or =81.0 nmol/l) compared with the lowest 25OHD (< or =43.9 nmol/l). This inverse association was not observed in non-Hispanic blacks. Homeostasis model assessment of insulin resistance (log e) was inversely associated with serum 25OHD in Mexican Americans (P=0.0024) and non-Hispanic whites (P=0.058) but not non-Hispanic blacks (P=0.93), adjusting for confounders. CONCLUSIONS These results show an inverse association between vitamin D status and diabetes, possibly involving insulin resistance, in non-Hispanic whites and Mexican Americans. The lack of an inverse association in non-Hispanic blacks may reflect decreased sensitivity to vitamin D and/or related hormones such as the parathyroid hormone.

Secular trends in dietary intake in the United States.

This review focuses on dietary intake and dietary supplement use among the U.S. population age 1-74 based on four National Health and Nutrition Examination Surveys conducted in 1971-74, 1976-80, 1988-94, and 1999-2000. Secular trends in intake of energy, macronutrients, cholesterol, sodium, calcium, iron, folate, zinc, vitamins A and C, fruits, vegetables, and grain products are summarized. During the 30-year period, mean energy intake increased among adults, and changed little among children age 1-19, except for an increase among adolescent females. Factors contributing to increases in energy intake include increases in the percentage of the population eating away from home (particularly at fast-food restaurants), larger portion sizes of foods and beverages, increased consumption of sweetened beverages, changes in snacking habits, and improved dietary methodology. Dietary supplement use increased among adult men and women, decreased among children age 1-5, and was stable for children age 6-11 and adolescents.

Diabetes, Impaired Fasting Glucose, and Elevated HbA1c in U.S. Adolescents: The Third National Health and Nutrition Examination Survey

OBJECTIVE —Using population-based data, we estimated the prevalence of diabetes, impaired fasting glucose, and elevated HbA 1c (>6%) levels in U.S. adolescents. RESEARCH DESIGN AND METHODS —The Third National Health and Nutrition Examination Survey (1988–1994) examined a representative sample of the U.S. population, which included 2,867 adolescents aged 12–19 years who had serum glucose measured. RESULTS —A total of 13 adolescents in the sample were considered to have diabetes; 9 reported using insulin, 2 reported using oral agents only, and 2 did not report any treatment but had high glucose levels (≥11.1 mmol/l regardless of length of fast or ≥7.0 mmol/l after an 8-h fast). Four of these cases (31% of the sample with diabetes) were considered to have type 2 diabetes. The estimated prevalence of diabetes (all types) per 100 adolescents ages 12–19 years was 0.41% (95% confidence interval 0–0.86). The prevalence of impaired fasting glucose (≥6.1 mmol/l) among adolescents without diabetes who had fasted for at least 8 h was 1.76% (0.02–3.50). The prevalence of elevated HbA 1c (>6%) was 0.39% (0.04–0.74). CONCLUSIONS —National data reflect the presence of type 2 diabetes in U.S. adolescents, but the survey sample size was not large enough to obtain precise prevalence estimates because of the relatively low prevalence.

Estimating the Energy Gap Among US Children: A Counterfactual Approach

OBJECTIVE. Our goal was to quantify the magnitude of energy imbalance responsible for the increase in body weight among US children during the periods 1988–1994 and 1999–2002. METHODS. We adopted a counterfactual approach to estimate weight gains in excess of normal growth and the implicit “energy gap”—the daily imbalance between energy intake and expenditure. On the basis of Centers for Disease Control and Prevention growth charts, we constructed weight, height, and BMI percentile distributions for cohorts 2 to 4 and 5 to 7 years of age in the 1988–1994 National Health and Nutrition Examination Survey (N = 5000). Under the counterfactual “normal-growth-only” scenario, we assumed that these percentile distributions remained the same as the cohort aged 10 years. Under this assumption, we projected the weight and height distributions for this cohort at 12 to 14 and 15 to 17 years of age on the basis of their baseline weight-for-age and stature-for-age percentiles. We compared these distributions with those for corresponding age groups in the 1999–2002 National Health and Nutrition Examination Survey (N = 3091) ∼10 years after the 1988–1994 National Health and Nutrition Examination Survey. We calculated differences between the counterfactual and observed weight distributions and translated this difference into the estimated average energy gap, adjusting for increased total energy expenditure attributable to weight gain. In addition, we estimated the average excess weight accumulated among overweight adolescents in the 1999–2002 National Health and Nutrition Examination Survey, validating our counterfactual assumptions by analyzing longitudinal data from the National Longitudinal Survey of Youth and Bogalusa Heart Study. RESULTS. Compared with the counterfactual scenario, boys and girls who were aged 2 to 7 in the 1988–1994 National Health and Nutrition Examination Survey gained, on average, an excess of 0.43 kg/year over the 10-year period. Assuming that 3500 kcal leads to an average of 1-lb weight gain as fat, our results suggest that a reduction in the energy gap of 110–165 kcal/day could have prevented this increase. Among overweight adolescents aged 12 to 17 in 1999–2002, results indicate an average energy imbalance ranging from 678 to 1017 kcal/day because of an excess of 26.5 kg accumulated over 10 years. CONCLUSIONS. Quantifying the energy imbalance responsible for recent changes in weight distribution among children can provide salient targets for population intervention. Consistent behavioral changes averaging 110 to 165 kcal/day may be sufficient to counterbalance the energy gap. Changes in excess dietary intake (eg, eliminating one sugar-sweetened beverage at 150 kcal per can) may be easier to attain than increases in physical activity levels (eg, a 30-kg boy replacing sitting for 1.9 hours with 1.9 hours walking for an extra 150 kcal). Youth at higher levels of weight gain will likely need changes in multiple behaviors and environments to close the energy gap.

Hypertension among adults in the United States: National Health and Nutrition Examination Survey, 2011-2012.

The overall prevalence of hypertension has not changed appreciably since 2009-2010. The age-adjusted prevalence of hypertension among U.S. adults was 29.1% in 2011-2012. Among adults with hypertension in 2011-2012, 82.8% were aware of their hypertension, 75.7% were currently taking medication to lower their blood pressure, and 51.9% had their blood pressure controlled to less than 140/90 mm Hg. Men and women had similar prevalence and awareness of hypertension, but more women than men were treating their hypertension and had it under control. Young adults aged 18-39 continued to have lower awareness, treatment, and control of their hypertension compared with older adults. Hypertension prevalence was still highest among non-Hispanic black adults. However, awareness, treatment, and control of hypertension were similar among non-Hispanic black, non-Hispanic white, and Hispanic adults. Non-Hispanic Asian adults had a lower prevalence of awareness than the other race and Hispanic origin groups, and lower treatment than non-Hispanic white and non-Hispanic black adults. However, hypertension control was similar among non-Hispanic Asian adults and the other race and Hispanic origin groups. Hypertension is a common and manageable chronic condition. Based on recent national data from 2011-2012, treatment of hypertension exceeded the Healthy People 2020 target goal of 69.5%. However, the control of hypertension has neither met the goal of the Healthy People 2020 (61.2% by 2020) nor the Million Hearts Initiative (65% by 2017). These results provide evidence for continued efforts to improve the management of hypertension in order to attain these goals.